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case study 1 Chief Complaint (CC) A 57-year-old man presents to the office with a complaint of left ear drainage since this morning. SubjectivePatient

May 27, 2025

case study 1

Chief Complaint
(CC) A 57-year-old man presents to the office with a complaint of left ear drainage since this morning.

SubjectivePatient stated he was having pulsating pain on left ear for about 3 days. After the ear drainage the pain has gotten a little better.

VS(T) 99.8°F; (RR) 14; (HR) 72; (BP) 138/90

General well-developed, healthy male

HEENTEAR: (R) external ear normal, canal without erythema or exudate, little bit of cerumen noted, TM- pearly grey, intact with light reflex and bony landmarks present; (L) external ear normal, canal with white exudate and crusting, no visualization of tympanic membrane or bony landmarks, no light reflex EYE: bilateral anicteric conjunctiva, (PERRLA), EOM intact. NOSE: nares are patent with no tissue edema. THROAT: no lesions noted, oropharynx moderately erythematous with no postnasal drip.

Skin No rashes

Neck/Throat no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;trachea midline

Answer the following questions:

What other subjective data would you obtain?
What other objective findings would you look for?

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